Parental Permission & Medical Authorization

Parental Permission & Medical Authorization

Participant Full Name: ______Birth date: ______

I give permission for my child (named above) to attend the worship service, Bible school, events, field trips, and service projects associated with the First Church of Christ of Fairborn, OH. I further give permission for my child to be transported to and from events by hired and volunteer drivers authorized by First Church of Church. This form is valid for a period of one year from the date signed below.

Medical Release

I hereby authorize the First Church of Christ ministry leaders, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.

Custody Release

I further authorize the First Church of Christ ministry leaders to receive physical custody of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to said adult.

Activity Release

I further give permission for my child to participate in all supervised activities except as noted:

______

______

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Signature of Parent or Legal GuardianPrinted name Date

EMERGENCY CONTACT INFORMATION

Participant Name: ______

Parent(s)/Guardian(s)

Name______

Home Phone ______Cell Phone ______

Work Phone______

Address______City ______Zip ______

Email Address ______

Name______

Home Phone ______Cell Phone ______

Work Phone______

Address______City ______Zip ______

Email Address ______

Other Emergency Contact

Name______

Home Phone ______Cell Phone ______

Work Phone______

Address______City ______Zip ______

Email Address ______

Are there any individuals with custody, visitation, or other legal restrictions associated with this child?

Name______Restriction______

Health Care Information

Participant Name: ______

Physician / Dentist
Name / Name
Phone / Phone
Medical Insurance Company / Dental Insurance Company
Policy/Group Number / Policy/Group Number
Name of Policy Holder / Name of Policy Holder

Please list any allergies to drugs, foods, plants, insects, etc:

Please list any prescription medication to be taken by the participant (including what it is taken for, when it is to be taken, dosage information, and any special procedures):

Please list any non-prescription (over-the-counter) medication you do NOT want dispensed to your child:

Please list any additional information relevant to participating in First Church of Christ activities (dietary needs; surgeries or serious injuries; chronic or recurring illness; medical conditions such as epilepsy or diabetes; psychiatric counseling or indications, etc.):